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Adherence
Unit 10
HIV Care and ART:
A Course for Physicians
Learning Objectives
 Define adherence in ART
 Describe the relevance and importance of
adherence in ART
 Identify barriers and factors affecting adherence
 Demonstrate how to assess client’s adherence
success
 Describe strategies for physicians to use with
clients to promote and encourage adherence
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What is Adherence?
 Adherence is:
 The patient’s active participation in planning care
 Understanding, consent and partnership in health
care delivery between the provider and patient
 Both adherence to care and adherence to
medications
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In Other Words…
 Adherence is a client’s behavior coinciding with
the prescribed health care regimen as agreed
upon through a shared decision making process
between the client and the health care provider
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Adherence vs. Compliance
 The term compliance is defined as acting in
accordance to a command. In health care, it is
often perceived as obeying a provider’s
instructions
 Unlike adherence, compliance is not based upon
shared decision-making between the patient and
provider
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Why is Adherence Important?
 ARV medication adherence is critically important
to:
 Achieve viral suppression
 Avoid viral resistance
 Prevent recurrence of OIs
 A patient’s best chance of ART success is to
remain on their first-line regimen of ART
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Sub-Optimal Adherence
Predisposes to Resistance
Sub-optimal adherence
Sub-therapeutic drug levels
Incomplete viral suppression
Generation of resistant HIV strains
by selection for mutant viruses
The association between poor adherence and
antiretroviral resistance is welldocumented1,2
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2
Adherence to Care and Treatment
Vanhove G, et al. JAMA. 1996.
Montaner JS, et al. JAMA. 1998.
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Missed Doses & Development
of Drug Resistance
 Drugs are prescribed at doses that will maintain an
effective level of drug in the bloodstream
 Dose is missed, taken late, or with the wrong type of
food: drug level in blood dips
 While levels are low, resistant viruses will reproduce
easily
 Resistant viruses gain a foothold before person begins
taking drugs consistently again
 Enough drug-resistant viruses may have emerged to cause
treatment failure
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Virologic Control Falls Sharply
With Diminished Adherence
(number of pills taken / number of
pills prescribed)
Source: Paterson, D. L. et. al. Ann Intern Med 2000;133:21-30
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Adherence to Medication
 The accepted definition of successful adherence
for most chronic diseases is >80% of pills taken
 This standard does not apply to HIV disease and
antiretroviral therapy
 Greater than 95% is the goal for ART
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Benefits of Adherence
 Through adherence, patients and providers can:

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
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Prevent opportunistic infections
Diagnose complications early
Improve outcomes of treatment and care
Delay emergence of drug resistance
Develop a positive patient-provider relationship
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Non-Adherence Factors
 Non-adherence is correlated with:
 Unstable emotional life or psychiatric illness
 Inability to fit the medication schedule into a daily
routine
 Missed clinic appointments
 Poor clinician-patient relationship
 Alcohol and drug abuse
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Non-Adherence Factors (2)





Lack of patient education
Side effects
Domestic violence
High pill burden
Cultural and religious beliefs
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Five Types of Non-adherers
1. Consistent Underdoser
 Regularly neglects to take one of the prescribed
doses, such as the midday dose
 Regularly takes only some of the prescribed
medications
2. Consistent Overdoser
 Regularly takes a drug more often or in larger doses
than is prescribed
3. Random Doser
 Takes the medications when she or he thinks of it
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Five Types of Non-adherers (2)
4. Abrupt Overdoser
 Does not take medications properly and then takes
an overdose prior to a clinic visit
 Doubles up for missed doses
5. Tourist (takes “drug holidays”)
 Abruptly stops all medications for a few days or
weeks
 Takes one day off per week
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Adherence to Care
 Assessment of adherence to care requires a
functioning, integrated administrative
infrastructure
 Adherence-to-care issues are most effectively
addressed when coordinated by a designated
person
 Regular and organized interdisciplinary
communication is an important adherence-tocare component – different members of the care
team have different “pieces of the puzzle”
 Nurses, pharmacists, counselors, outreach workers
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Assessing Adherence
 Health-care providers cannot accurately discern
which patients will adhere
 Providers must formally assess adherence
 An interdisciplinary assessment approach is
most successful
 Intensive assessment should be conducted
during ARV initiation
 Assessment is a continual process that must be
revisited during every patient interaction
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Assessing Adherence (2)
 Assessment requires a supportive and
nonjudgmental approach
 Acknowledge that medication adherence is
difficult
 Assess missed doses
 Assess barriers to adherence and support
strategies
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Assessing Adherence (3)
 Examples of questions to assess missed doses:
 “Many patients taking these medications find it difficult
from time to time. What has your experience been?”
 “How many doses have you missed in the past day?
The past week? The past month?”
 “In an average week, how often do you miss your
medications? How often are you late?”
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Assessing Adherence (4)
 Examples of questions to assess barriers or
support strategies:
 “When is it most difficult to remember your
medications?”
 “It’s not easy to take medicine every day. What things
help you to take your pills?”
 “What kinds of problems make it hard to take your
pills?”
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Assessing Adherence (5)
 Do not assume “once adherent, always
adherent”
 Many things can change over time
 Patients may tire of taking medications – pill fatigue
 Family structure may change causing new adherence
challenges
 After clinical improvement occurs, patients may
assume they no longer need medications
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Barriers to Adherence
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
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
Cultural beliefs or fears about medication
Secrecy and stigma surrounding HIV diagnosis
Side effects
Difficulty swallowing medicines
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Barriers to Adherence (2)
 Inadequate understanding of medicine regimen
 Competing priorities: work, child care, food
access
 Forgetfulness or lack of support to remember
 Travel or being away from home
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Promoting Adherence
 Care Setting:

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Welcoming and comfortable environment
Accessible, with co-located services
Convenient hours for work, child care
Reimbursement for transportation costs
Child care or facilities at clinic
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Promoting Adherence (2)
 Communication:
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Ask patients to restate information given
Practice active listening
Ask open-ended questions to facilitate patient sharing
Restate answers to ensure understanding
Show concern and respect
Be non-judgmental
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Promoting Adherence (3)
 Confidentiality:
 Explain to all patients upon enrollment
 Assure that HIV status will not be disclosed without
consent
 Counsel about the importance of discretion regarding
other patients
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Promoting Adherence (4)
 Outreach and Follow-Up:
 Develop processes to contact patients
 Plan to address missed appointments
 Consistently obtain specific patient contact
information
 Document patient’s preferred contact method
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Adherence Readiness
Prior to ARV Initiation
 ARV initiation is rarely a medical emergency
 Adherence counseling and preparedness must
precede ARV therapy
 Patients should demonstrate adherence to care
 Does the patient keep clinic appointments reliably?
 Practice with OI prophylaxis
 Ideally, patients should identify an “adherence
buddy” for ongoing support
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Strategies to Promote
Medication Adherence
 Prescribing Medications:
 Personalized medication regimen for patient’s lifestyle
 Detailed instructions on how to take medications,
including timing, food restrictions, drug interactions
 Instructions on how to identify and handle adverse
effects
 Streamlined regimens minimizing the number of pills
and doses per day
 Pill boxes
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Strategies to Promote
Medication Adherence (2)
 Access to Medication:
 Ensure easy access to uninterrupted medication
supply (avoid “stock outs”)
 Ensure that patients understand where, when and
how to obtain medications
 Provide on-site pharmacies where possible
 Assist patients in safeguarding medications
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Strategies to Promote
Medication Adherence (3)
 Counseling and Support:
 Peer support groups
 Patient education and counseling
 Identify barriers to adherence and provide
individualized interventions
 Modified directly observed therapy either in the home
by a community based medication partner or at the
clinic
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Strategies to Promote
Medication Adherence (4)
 Counseling and Support (cont):
 Medication “reminders” linked to daily activities,
timers, beepers, alarm clocks
 Medication partners or “buddies”
 Tips on how to remember medications, including daily
cues, reminders, partners
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ART Counseling
 Team approach, including physician, nurse,
pharmacist, laboratory technician and counselor
 The team provides information to each other to
improve quality of care
 Team ensures confidentiality
 Involve family members and other care
providers
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Objectives of ART Counseling
 Provide information and help patients:
 Make decisions about antiretroviral therapy
 Cope with therapy
 Protect others and maintain positive sexual behavior
changes
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Counseling Patients Before ART
 Ensure patients received pre- and post-test
counseling
 Issues to discuss:
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Financial
Adherence
Emotional support
Information about therapy
Disclosure
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Counseling Patients Before ART (2)
 Issues to discuss (cont.):
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Specific ART drug information
Drug adherence
Coping with response to ART
Sexual behavior change
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Group Exercise: Adherence
Counseling Role Play
Key Points
 Adherence to care and/or treatment is critical for
continued viral suppression and improvement in immune
function
 Serious potential consequences can result from nonadherence
 >95% adherence is necessary to achieve <20% failure
rate
 Benefits of adherence to care include prevention of
opportunistic infections, early diagnosis of complications,
and development of positive patient-provider
relationships
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Key Points (2)
 Antiretroviral (ARV) regimens are complex, may
have major side efforts and may pose difficulty
with adherence
 Patient/family education and involvement are
critical for successful treatment of HIV infection
 Physicians should promote and encourage
disclosure of HIV status to a patient’s trusted
family member and/or friend to help promote
successful adherence
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Key Points (3)
 A therapeutic alliance between the provider and
the patient can promote optimal adherence to
both HIV care and ARV regimens
 Adherence CAN be improved
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